Wednesday, August 23, 2017

Physical comorbidities and poor treatment adherence appear to be associated with both a failure to remit and a longer time to remission of depression, according to a report using data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. The findings, which were reported in Depression and Anxiety, point to the importance of interventions aimed at improving treatment adherence and addressing both the physical and mental health needs of the patient.

STAR*D, a multisite, multistep, prospective, randomized trial, compared the effectiveness of several medications or combinations of medications in adults aged 18 to 75 with major depressive disorder. Those who did not become symptom-free during one level of treatment could move the next level of treatment. Relying on data from 3,606 patients in STAR*D, Ramin Mojtabai, M.D., Ph.D., M.P.H., of Johns Hopkins University used statistical modeling to distinguish patients whose depression symptoms did not remit during the trial from those whose symptoms did remit and to characterize risk factors for each.

According to this analysis, 14.7% of the STAR*D participants were estimated to be nonremitters. Over the course of the 12-month trial, time to remission varied considerably among remitters.

“This finding is consistent with the past research on the treatment of chronic depression and is an important consideration when deciding on the length of a new medication treatment trial for patients who have not responded to prior trials,” Mojtabai wrote. “These patients may need a longer period than the 4-8 weeks recommended in the current practice guidelines to fully respond to a treatment regimen.”

Failure to remit was significantly associated with not having a college education, current unemployment, and longer duration of depressive episode. Longer time to remission was significantly associated with seeking care at a specialty treatment setting, poorer mental health functioning assessed by the 12-item Short-Form Health Survey, and impairment in role functioning assessed by the Work and Social Adjustment Scale.

“Treatment resistance is often clinically defined by nonremission after two adequate antidepressant medication treatment trials. Yet, treatment-resistant cases are likely heterogeneous, [composed] of those who would remit in response to treatment more slowly and those who would not remit and would have a chronic course,” Mojtabai wrote. “Being able to distinguish nonremission from a longer time to remission among the remitters has important implications for understanding the causes of treatment resistance and for treatment planning.”

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